FAST TRACK FORM

Step 1 of 3 - Choose Category

Type of Application(Required)

Newly Apply

Renewal Case ( previously applied with Medindemnity )

Choose Professional Healthcare Services

There are 5 main category fields. Please select one of the category and proceed with the "Next" button below after you have selected and confirm the yearly premium.

Healthcare Services

BENEFIT AT A GLANCE

Please choose your prefer date to start cover

From(Required)

To(Required)

Optional Benefits

Aggravated Damages

Yes - subject to additional 10% Premium

Aggravated damages are what the court will order doctors to pay on top of the claims such as emotional stress caused by negligence

Auto Reinstatement

Yes - subject to additional 10% Premium

When the existing coverage limit is exhausted during claims then policy will automatically reinstated full coverage amount which can be utilized for subsequent claims

YOUR TOTAL PREMIUM - includes SST 6%, stamp, transaction fee and optional extension (if any)

Are you Foreign Doctor ?(Required)

Yes

Gender

Country

Name(Required)

IC Number(Required)

Passport Number(Required)

Phone(Required)

Email(Required)

Date of Birth(Required)

Any changes of your practice address?(Required)

Yes

Primary Practice Address ( Clinic / Hospital )(Required)

Address Line 1 Address Line 2 City State Poscode

Please state : Licensing body

Please state : Registration number

Claim History - Have any claims been made against you ; aware of any circumstances & allegations being made against you ; have you been the subject of disciplinary action by professional body ; have you had criminal charges brought against you ?(Required)

Yes

Please provide full details and status of each claim.